Bacharach Medical History Form
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1
2Patient Name: __________________________________
MEDICAL HISTORY FORM
Account #:
__________________________________
Eval. Date: ______________ DOB: ______________
Patient Identification
Diagnosis: ___________________________________
What language are you most comfortable speaking with your
WHERE DO YOU LIVE?
therapist? __________________________________________
Private home
1-story
2-story
Would you like an interpreter?
Yes
No
Private apartment
1-story
2-story
Other ___________________________
HISTORY OF CURRENT PROBLEM
The condition you are starting or continuing therapy for was a
WITH WHOM DO YOU LIVE?
result of:
Alone
Child (no spouse)
Vehicle Accident
Fall
Spouse only
Other relatives
Athletic Activity
Lifting/Carrying
Spouse and others
Group Setting
Repetitive Motion/Overuse
Sustained position
Personal care attendant
Gradual Onset
Sudden Onset/No Trauma
Other: __________________________
Pulling/pushing/climbing
Assault
DOES YOUR HOME HAVE
Other__________________________________________
Stairs, no railing
How many? _______
1. When did the problem(s) begin? Date ___/____/____
Stairs, railing
How many? _______
2. Have you ever had this problem/injury before?
Steps to enter
How many? _______
Yes
No (go to Question # 6)
Ramps
Elevator
Uneven terrain
3. What did you do for the problem/injury?________________
Other obstacles ____________________
_______________________________________________
DO YOU USE
4. Did the problem/injury get better?
Yes
No
Cane
Crutches
Walker/Rollator
5. About how long did the problem last? ________________
Wheelchair:
Manual
Motorized
6. What are you doing now to improve your problem/injury?
Other ___________________________
_______________________________________________
7. Have you received any therapy this calendar year?
HAND DOMINANCE
Yes
No
Left
Right
Where? ________________________________________
How many visits? PT ____ OT ____ Speech ____
8. What are your goals for therapy?
FOR WOMEN: Are you pregnant, or think you
1. _______________________________________________
might be pregnant?
Yes
No
2.____________________________________________________
CURRENT LIMITATIONS: (Check all that apply)
FOR MEN: Have you been diagnosed with
Bed Mobility (change position in bed)
prostate disease?
Yes
No
Transfers such as moving bed to chair, chair to commode
Walking on
level surfaces
stairs
ramps
Do you have a history of a resistant bacteria,
uneven terrain
such as MRSA? Or if hospitalized, did staff wear
Difficulty with self-care (bathing, dressing, eating, toileting)
Difficulty with home management (chores, shopping, etc. )
gowns and gloves each time they entered the
Difficulty with community and work activities
room?
Yes
No
Out of work/school
No participation in recreation or leisure activities
Lifting
FALL RISK ASSESSMENT
Communication Problem
Have you fallen in the past three months?
Yes
No
Bacharach can discuss my health information with the
following persons who are involved in my care:
Have you traveled outside the United States in
___________________________________________________
the past 10 days?
No
Yes- please tell us
___________________________________________________
where _____________________________
_________________________________________
None
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